Options for Combination Therapy in Type 2 Diabetes: Comparison of the ADA/EASD Position Statement and AACE/ACE Algorithm  Timothy Bailey, MD  The American Journal of Medicine  Volume 126, Issue 9, Pages S10-S20 (September 2013) DOI: 10.1016/j.amjmed.2013.06.009 Copyright © 2013 Terms and Conditions

Figure 1 American Diabetes Association (ADA)/European Association for the Study of Diabetes (EASD) general recommendations for antihyperglycemic therapy in type 2 diabetes (© ADA, and reproduced with permission from Inzucchi et al. Diabetes Care. 2012;35:1364-1379).4 DPP-4i = dipeptidyl peptidase-4 inhibitor; FX = fracture; HF = heart failure; GI = gastrointestinal; GLP-1 = glucagon-like pepide-1; SU = sulfonylurea; TZD = thiazolidinedione. Moving from the top to the bottom of the figure, potential sequences of antihyperglycemic therapy. In most patients, begin with lifestyle changes; metformin monotherapy is added at, or soon after, diagnosis (unless there are explicit contraindications). If the A1c target is not achieved after 3 months, consider one of the 5 treatment options combined with metformin: a sulfonylurea, TZD, DPP-4 inhibitor, GLP-1 receptor agonist, or basal insulin. (The order in the chart is determined by historical introduction and route of administration and is not meant to denote any specific preference.) Choice is based on patient and drug characteristics, with the over-riding goal of improving glycemic control while minimizing side effects. Shared decision-making with the patient may help in the selection of therapeutic options. The figure displays drugs commonly used in both the US and Europe. Rapid-acting secretagogues (meglitinides) may be used in place of sulfonylureas. Other drugs not shown (a-glucosidase inhibitors, colesevelam, dopamine agonists, pramlintide) may be used where available. aConsider beginning at this stage in patients with very high A1c (eg, >9%). bConsider rapid-acting, nonsulfonylurea secretagogues (meglitinides) in patients with irregular meal schedules or who develop late postprandial hypoglycemia on sulfonylureas. The American Journal of Medicine 2013 126, S10-S20DOI: (10.1016/j.amjmed.2013.06.009) Copyright © 2013 Terms and Conditions

Figure 2 AACE/ACE treatment algorithm for the management of type 2 diabetes (© ACE, and reproduced with permission from Garber et al. Endocr Pract 2013;19:327-336).2 A1c = glycated hemoglobin; AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; AGI = alpha-glucosidase inhibitors; DPP-4i = dipeptidyl peptidase 4; GLN = L-glutamine; GLP-1RA = glucagon-like peptide-1 receptor agonist; SGLT-2 = sodium/glucose cotransporter 2; SU = sulfonylurea, TZD = thiazolidinediones; QR = quick release. Within each category of A1c, there is a progression from monotherapy, to dual therapy, to triple therapy, to insulin therapy with or without additional agents. The order of presentation of regimens indicates general priorities that should be customized to the individual patient, with consideration of the contraindications and precautions, allergies, comorbid conditions, drug–drug interactions, and drug–laboratory interactions. Physicians must be thoroughly familiar with complete prescribing information before selection of therapy. In each case, response to therapy should be monitored closely (determination of A1c every 2 to 3 months), and titration of dosages or changes of regimen should be implemented in a timely manner. The American Journal of Medicine 2013 126, S10-S20DOI: (10.1016/j.amjmed.2013.06.009) Copyright © 2013 Terms and Conditions